Gold Health Home Care Corp

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on the review of the Agency’s Error Summary report and Staff interview, the Agency failed to submit timely reports for 128 of 365 reports submitted for the last 12 months. Finding include: 1. The Agency’s Error Summary report for 09/01/2024 thru 08/31/2025, was reviewed on 09/18/25 at 2:40 PM. The report documented 35.07% of the OASIS reports were submitted late. 2. The above findings were confirmed, during the interview with the Administrator, on 09/18/25 at 3:30 PM.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record review and Staff interviews, the Agency failed to ensure in 5 of 7 (Pts. #1, 3, 4, 5 and 6) clinical records reviewed, the PsOC were followed. 5. Pt. #6 was admitted to home health services on 06/27/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 09/19/25 and included the POC for certification period of 08/26/24 to 10/24/24 which required, “Orders for Discipline and Treatments… SN Frequency: 1x per week for 9 weeks, 1-2 PRN visits for disease/medication management, abnormal vital signs.” The clinical record lacked documentation of skilled nursing visits for the week of 09/07/24 to 09/13/24. The record lacked a Physician notification of the missed visit or a Physician order for a change in the visit frequency. 6. During interviews with the Administrator on 09/19/25 between 11:00 AM to 1:00 PM, it was confirmed that all physician orders should be followed. During the same interviews, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 08/06/25 with the diagnosis of Pressure Ulcer of Right buttock, stage 3. The clinical record was reviewed on 09/19/25. The clinical record included the PsOC (for Start of Care and Resumption) effective 08/06/25 to 10/04/25, and required: “…Orders for Discipline and Treatment….Notify Physician of vital sign parameters out of range:….Heart Rate: …( 09/05/25, that lacked a blood sugar assessment as ordered. The clinical record also included a Skilled Nursing visit note dated 09/05/25, that indicated a Heart rate of 57. The record lacked documentation that the Physician was notified for parameters falling out of range. 2. Pt. #3 was admitted to the home health services on 09/19/25 with the diagnosis of Unspecified Atrial Fibrillation and Type 2 Diabetes Mellitus with diabetic polyneuropathy . The clinical record was reviewed on 09/19/25. The clinical record contained a POC dated 08/02/25, that required the PT to visit the patient 1 time a week for 1 week and 2 times a week tor 1 week and 1 time a week for 7 weeks. The PT failed to make the 2nd visit during the week of 08/09/25 (week #2). 3. Pt. #4 was admitted to the home health services on 06/13/25 with the diagnosis of Other Spondylosis with Myelopathy Thoracic Region. The clinical record was reviewed on 09/19/25. The clinical record contained a POC dated 06/13/25, that required the SN to visit the patient 1 time a week for 9 weeks. The SN failed to make the visit during the week of 06/22/25 (week #3). 4. Pt. #5 was admitted to the home health services on 06/16/25 with the diagnosis of “Hemiplga following Cerebral Infrc aff right dominant side”. The clinical record was reviewed on 09/19/25. The clinical record contained a POC dated 06/16/25, that required the SNto visit the patient 1 time a week for 9 weeks. The SN failed to visit during the week of 7/27/25 (week #7).”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on the clinical record review and Staff interview, the Agency failed to ensure in 4 of 7 (Pts. #1, 7, 3 and 6) clinical records reviewed, the clinical records were completed as required. 5. Pt. #6 was admitted to home health services on 06/27/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 09/19/25. The clinical record included SN notes, which included documentation of the patient’s weights: 06/27/24 - 215 pounds, 07/02/24 - 221 pounds, 07/09/24 – 240 pounds, 07/17/24 – 215 pounds, 07/26/24 – 245 pounds, 08/01/24 – 215 pounds, 08/15/24 – 245 pounds…09/23/24 – 245 pounds, 10/02/24 – 215 pounds, 10/03/24 – 240 pounds. During an interview with the Administrator on 09/19/25, it was stated that the actual weight of the Pt. would be closer to 215 pounds which was taken by the RN during SOC and the 240 - 245 pounds weight recorded are inaccurate. 6. During interviews with the Administrator on 09/19/25 from 11:00 AM to 1:00 PM, it was confirmed that the clinical records should contain complete and accurate information. During the same interviews, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 08/06/25 with the diagnosis of Pressure Ulcer of Right buttock, stage 3. The clinical record was reviewed on 09/19/25. The clinical record included an SN visit note dated 09/05/25, that lacked documentation of vital signs and the clinician’s signature and date. 2. Pt. #7 was admitted to home health services on 07/23/24 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 09/19/25. The clinical record lacked documentation of an admission consent/service agreement for the Agency to provide services. During an interview with the Administrator on 09/19/25 at 12:00 PM, the Administrator confirmed that the Pt. consented to service, but the Agency failed to obtain admission documents for Pt. #7 from the admitting SN. 3. Pt. #3 was admitted to the Home Health Services on 09/19/25 with the diagnosis of Unspecified Atrial Fibrillation and Type 2 Diabetes Mellitus with diabetic polyneuropathy . The clinical record was reviewed on 09/19/25. The clinical record lacked the consent for care for the current episode. 4. Pt. #5 was admitted to the Home Health Services on 09/19/25 with the diagnosis of “Hemiplga following Cerebral Infrc aff right dominant side”. The clinical record was reviewed on 09/19/25. The clinical record lacked the form used for the documentation of the SN missed visit notes for 07/27/25 (week #7).”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on review of Agency’s Pt. Admission folder, clinical record review, observation during a home visit, and Staff interview, the Agency failed to ensure in 2 of 7 (Pts. # 1 and 7) clinical records reviewed, the Pt. / representative was informed in writing of the services to be provided and the frequency of visits. Findings include: 1. Pt. #1 was admitted to home health services on 08/06/25 with the diagnosis of Pressure Ulcer of Right buttock, stage 3. The clinical record was reviewed on 09/19/25. The clinical record included a form titled: Initial Discharge Planning, dated and signed by the SN on 08/06/25 (at the SOC), and included “Disciplines/Frequency:” The form included a check mark on SN (Skilled Nursing) but lacked proposed frequency. The form lacked proposed discipline for PT service and frequency. During a home visit conducted with the Alternate Agency Supervisor on 09/19/25 at 2:30 PM for Pt. # 1, the admission folder was observed and lack documentation indicating the Pt. / representative was notified of the discipline (s) to provide service, and the frequency of visits in writing. 2. Pt. #7 was admitted to home health services on 07/23/24 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 09/19/25. The clinical record lacked documentation the patient was informed in writing of the proposed SN, PT and HHA services to be provided and visit frequencies. 3. During an interview with the Administrator on 09/19/25 at 12:00 PM, the Administrator confirmed the above findings.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on clinical record review and Staff interview, the Agency failed to ensure in 1 of 2 (Pt. 7) discharged records reviewed, a comprehensive assessment was completed at discharge. Findings include: 1. Pt. #7 was admitted to home health services on 07/23/24 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 09/19/25. The clinical record included a transfer assessment date 08/09/24, indicating Pt. 7 was transferred to an inpatient facility but not discharged from Agency. The Physician order dated 08/21/24, indicated discharge from all home health agency services. As of 09/19/25, the clinical record lacked documentation that a comprehensive assessment was updated at discharge. 2. During an interview with the Administrator on 09/19/25 at 12:00 PM, the Administrator confirmed the above findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical record review, home visit interview/observations and Staff interviews, the Agency failed to ensure in 3 of 7 (Pts. #1, 3 and 5 ) clinical records reviewed, the PsOC included all Pt. specific interventions related to Pts. diagnosis. 2. Pt. #3 was admitted to the home health services on 09/19/25 with the diagnosis of Unspecified Atrial Fibrillation and Type 2 Diabetes Mellitus with diabetic polyneuropathy . The clinical record was reviewed on 09/19/25. A home visit was conducted on 09/20/25 at 12:30 PM, with the PT. During the Patient interview, it was stated and observed the use of Biofreeze and Aspere Cream for pain. The clinical record contained a POC dated 08/02/25, that lacked the Biofreeze and Aspere Cream. 3.Pt. #5 was admitted to the home health services on 06/16/25 with the diagnosis of “Hemiplga following Cerebral Infrc aff right dominant side”. The clinical record was reviewed on 09/19/25. The clinical record contained a POC dated 06/16/25, that required the SN to assess the patient’s blood glucose 1 time a week for 9 weeks. The POC lacked the diagnosis for the blood glucose testing. 4. The above findings were confirmed, during the interviews with the Administrator on 09/19/25 between 11:00 AM and 12:00 PM, and on 09/22/25 with the Agency Supervisior and Administrator. Findings include: 1. Pt. #1 was admitted to home health services on 08/06/25 with the diagnoses of Pressure Ulcer of Right buttock, stage 3, Pressure Ulcer of Left buttock, stage 3, Pressure Ulcer of sacral region, stage 3, Chronic venous hypertension with ulcer of bilateral lower extremities, Non-pressure chronic ulcer other part right low leg with fat layer exposed, Non-pressure chronic ulcer other part left low leg with fat layer exposed. The clinical record was reviewed on 09/19/25. The clinical record included a POC effective 08/06/25 to 10/04/25, and required SN: “….do wound care treatment on Right and Left leg every visit...” The POC included 2 different wound care treatment orders for the same bilateral leg ulcer sites. A home visit was conducted for Pt. #1 on 09/19/25 at 2:30 PM with Alternate Agency Supervisor. Pt. #1 confirmed, that Pt. has pressure ulcer on the sacral area from the recent hospital discharge and stated that the caregiver places foam and tape on the site. The POC lacked Pt. specific interventions for the sacral ulcer wound.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on clinical record review and Staff interview, the Agency failed to ensure in 3 of 7 (Pts. #1, 7 and 6) clinical records reviewed, Pts. were assessed for the status of Influenza and/or Pneumonia vaccination. 3. Pt. #6 was admitted to home health services on 06/27/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 09/19/25. The clinical record included an untitled document signed by both Pt. #6 and the RN that included documentation of the patient’s vaccination assessment. The section “Influenza Vaccine” was blank. The record lacked documentation of the patient’s vaccination status for Influenza. 4. During interviews with the Administrator on 09/19/25 from 11:00 AM to 1:00 PM, it was stated the patient’s vaccination assessment is completed using the (above-mentioned) form at SOC. During the same interviews, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 08/06/25 with the diagnosis of Pressure Ulcer of Right buttock, stage 3. The clinical record was reviewed on 09/19/25. The clinical record included a form on Influenza and Pneumonia vaccination, signed by the SN and the Pt. dated 08/06/25 (at SOC), but lacked a complete assessment for Influenza and Pneumonia vaccination. 2. Pt. #7 was admitted to home health services on 07/23/24 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 09/19/25. The clinical record lacked an assessment at the SOC, for the need for Influenza and/or Pneumonia vaccination.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical record review and Staff interview, the Agency failed to ensure in 2 of 3 (Pt. #1 and 6) clinical records with transfer or discharge, the transfer or discharge summary was sent to the receiving facility and/or Physician. 2. Pt. #6 was admitted to home health services on 06/27/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 09/19/25. The record included a discharge comprehensive assessment dated 10/24/24, indicating that Pt. #6 was discharged from the Agency. The record lacked documentation that a copy of the discharge summary was sent to the Physician. 3. During interviews with the Administrator on 09/19/25 from 11:00 AM to 1:00 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 08/06/25 with the diagnosis of Pressure Ulcer of Right buttock, stage 3. The clinical record was reviewed on 09/19/25. The transfer assessment and summary dated 08/12/25, lacked the date that the transfer summary was sent to the receiving facility.”